What are the recommendations for pain management?

Comprehensive Pain Management Recommendations

Physical activity and exercise interventions, combined with psychological approaches, are the most effective strategies for managing pain across different conditions, with specific treatment modalities tailored to the location and type of pain. 1

Pain Assessment

A thorough pain assessment should include:

• Pain characteristics (severity, type, spread, quality)
• Previous and ongoing pain treatments and their perceived efficacy
• Current inflammation and joint damage as sources of pain
• Pain-related disability factors
• Psychological factors (beliefs, emotions, catastrophizing)
• Social influences related to pain
• Sleep problems
• Presence of obesity 2

Treatment Algorithm

Step 1: Education and Self-Management

• Provide educational materials about pain management
• Implement psychoeducation about pain mechanisms
• Offer self-management interventions (online or face-to-face) 2

Step 2: Non-Pharmacological Approaches

Physical Activity and Exercise

• For patients able to initiate activity independently: Provide advice to stay active
• For patients needing assistance: Refer to physiotherapy for individualized graded exercise or strength training
• For patients with psychosocial barriers (fear of movement, catastrophizing): Consider multidisciplinary intervention including cognitive-behavioral therapy 2, 1

Psychological Interventions

• Cognitive-behavioral therapy
• Acceptance and commitment therapy
• Mindfulness-based programs 3

Assistive Devices and Adaptations

• Orthotics (splints, braces, gloves, sleeves, insoles)
• Daily living aids
• Ergonomic adaptations at home/workplace 2

Step 3: Pharmacological Management

For Mild Pain (WHO Level I)

• Acetaminophen: 2 caplets (each 325mg or 500mg) every 8 hours, maximum 6 caplets in 24 hours 4
• NSAIDs (e.g., Ibuprofen): 400mg every 4-6 hours as needed for pain relief, not exceeding 3200mg daily 5, 1

For Neuropathic Pain

Follow a stepped approach:

1. First-line: Secondary-amine tricyclic antidepressants (nortriptyline, desipramine) or selective serotonin norepinephrine reuptake inhibitors (duloxetine, venlafaxine)
2. First-line alternative: Calcium channel α2-δ ligands (gabapentin, pregabalin)
3. For localized peripheral neuropathic pain: Topical lidocaine
4. For acute neuropathic pain or cancer pain: Consider opioid analgesics or tramadol 2, 6

Step 4: Multidisciplinary Treatment

For patients with inadequate response to previous steps, consider referral to specialized pain centers that offer comprehensive multidisciplinary approaches 2

Special Considerations

For Inflammatory Pain

• Treat the underlying inflammation first 1
• Use NSAIDs with caution in patients with inflammatory bowel disease 1

For Elderly Patients

• Start with lower doses and titrate slowly 1
• For patients with cardiac disease, use tricyclic antidepressants with caution, limiting dosages to less than 100mg/day 2

Common Pitfalls to Avoid

1. Overreliance on pharmacological treatments without maximizing non-pharmacological approaches 1, 7
2. Failing to reassess pain after implementing interventions 1
3. Using opioids for chronic non-cancer pain without proper risk assessment 1, 3
4. Dismissing pain reports when physical findings don't correlate with reported intensity 1
5. Not considering psychosocial factors that influence pain perception 1

Monitoring and Follow-up

• Reassess pain and health-related quality of life frequently
• If substantial pain relief (e.g., average pain reduced to ≤3/10) and tolerable side effects, continue treatment
• If partial pain relief (e.g., average pain remains ≥4/10), add another first-line medication
• If inadequate pain relief (<30% reduction), switch to an alternative first-line medication 2

This comprehensive approach to pain management emphasizes the importance of non-pharmacological interventions as first-line treatments while providing clear guidance on appropriate pharmacological options when needed.